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History and Physical - Update Requirements

When is an update to a history and physical required?

Any examples are for illustrative purposes only.

When a history and physical (H & P) is completed within 30 days PRIOR TO inpatient admission or registration of the patient, an update is required within 24 hours AFTER the patient physically arrives for admission/registration but prior to surgery or a procedure requiring anesthesia services.  For example, if an H & P was completed in a physician’s office at 3:00 pm today for a procedure to be performed at 9:00 am tomorrow, an update would be required AFTER the patient arrives for the procedure tomorrow morning but prior to the 9:00 am procedure time. The 24 hour time frame starts when the patient physically presents for admission/registration.  NOTE: The term 'registration' generally applies to patients scheduled for same day or outpatient procedures. Any H & P completed greater than 30 days prior to inpatient admission or registration cannot be updated and a new H & P must be completed.

NOTE: A properly executed history and physical is valid for the entire length of stay.  Any changes to the patient’s condition would be documented in the daily progress notes.  A new H & P or update to the H & P is not required when the patient remains continuously hospitalized. If the patient has been discharged, then readmitted, there must be a valid history and physical (no greater than 30 days) and updated within 24 hours after re-admission/registration but prior to a surgical procedure or other procedure requiring anesthesia.
Last updated on March 04, 2021
Manual: Critical Access Hospital
Chapter: Provision of Care Treatment and Services PC

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